Fraud, Waste, and Abuse Plan

Community First Health Plans recognizes that the detection, investigation and prevention of waste, abuse and fraud are vital to maintaining an affordable health care system in this state and country. Community First has mounted a sincere effort to limit waste, fraud and abuse through the efforts summarized in the Community First Anti-Fraud Work Plan.

Community First is committed to protect and preserve the integrity and availability of health care resources to our recipients, our healthcare partners and the general community. Community First performs these activities through its Special Investigation Unit to detect, prevent and eliminate waste; abuse and fraud at the provider, recipient and health plan level. Community First utilizes electronic systems and training of our employees, contractors and agents to identify and report possible acts of waste, abuse and fraud. When such acts are identified, Community First seeks effective remedies to identify overpaid amounts; prevent future occurrences of waste, abuse and fraud; and report offenses to the appropriate agencies.

Fraud is an intentional representation that an individual knows to be false or does not believe to be true and makes, knowing that the representation could result in some unauthorized benefit to himself/herself or some other person.

If you suspect a person who receives benefits or a provider (a doctor, dentist, counselor, etc.) has committed waste, abuse or fraud, you have a responsibility and a right to report it.

Reporting Waste, Abuse or Fraud by a Provider or Client

You can report directly to your health plan any providers or clients you suspect of waste, abuse or fraud by completing the following forms and mailing to address below or faxing to the number below. You may also leave an anonymous message by calling the Community First Hotline.

Or if you can get on the Internet, go to www.hhsc.state.tx.us and select the "Reporting Waste, Abuse and Fraud" tab on the left side of the screen. The site tells you about the types of waste, abuse and fraud to report. You may also go to https://oig.hhsc.texas.gov/ to report suspected fraud, waste, or abuse by a member/or provider. If you would rather speak to someone, please call the HHSC Office of Inspector General Fraud Hotline at 1-800-436-6184. You may also send a note or letter to the following addresses: